Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. C. Frerk et al. Difficult Airway Society: Intubation guidelines working group. British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371
Aslani, A., Ng, S.-C., Hurley, M., McCarthy, K. F., McNicholas, M., & McCaul, C. L. (2012). Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesthesia and Analgesia, 114(5), 987–992. http://doi.org/10.1213/ANE.0b013e31824970ba
Bair, A. E., & Chima, R. (2015). The Inaccuracy of Using Landmark Techniques for Cricothyroid Membrane Identification: A Comparison of Three Techniques. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, 22(8), 908–914. http://doi.org/10.1111/acem.12732
Bennett, J. D., Guha, S. C., & Sankar, A. B. (1996). Cricothyrotomy: the anatomical basis. Journal of the Royal College of Surgeons of Edinburgh, 41(1), 57–60.
Boon, J. M., Abrahams, P. H., Meiring, J. H., & Welch, T. (2004). Cricothyroidotomy: a clinical anatomy review. Clinical Anatomy (New York, NY), 17(6), 478–486. http://doi.org/10.1002/ca.10231
Buonopane, C. E., Pasta, V., Sottile, D., Del Vecchio, L., Maturo, A., Merola, R., et al. (2014). Cricothyrotomy performed with the Melker™ set or the QuickTrach™ kit: procedure times, learning curves and operators’ preference. Il Giornale Di Chirurgia, 35(7-8), 165–170.
Cook, T., Woodall, N., & Frerk, C. (2015). Appendix 4 NAP4 Summary: major complications of airway management in the United Kingdom. British Journal of Anaesthesia (2011) 106 (5): 617-631. https://doi.org/10.1093/bja/aer058
Frerk, C., Mitchell, V. S., & McNarry, A. F. (2015). Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia (2015) 115 (6): 827-848. https://doi.org/10.1093/bja/aev371
Hubert, V., Duwat, A., Deransy, R., Mahjoub, Y., & Dupont, H. (2014). Effect of simulation training on compliance with difficult airway management algorithms, technical ability, and skills retention for emergency cricothyrotomy. Anesthesiology, 120(4), 999–1008. http://doi.org/10.1097/ALN.0000000000000138
Langvad, S., Hyldmo, P. K., Nakstad, A. R., Vist, G. E., & Sandberg, M. (2013a). Emergency cricothyrotomy–a systematic review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21, 43. http://doi.org/10.1186/1757-7241-21-43
Nakstad, A. R., Bredmose, P. P., & Sandberg, M. (2013). Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21, 59. http://doi.org/10.1186/1757-7241-21-59
Prithishkumar, I. J., & David, S. S. (2010). Morphometric analysis and clinical application of the working dimensions of cricothyroid membrane in south Indian adults: With special relevance to surgical cricothyroidotomy. Emergency Medicine Australasia, 22(1), 13–20. http://doi.org/10.1111/j.1742-6723.2009.01245.x
The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational Affairs Committee. (1999). The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational Affairs Committee. Clinical Anatomy (New York, NY), 12(1), 43–54. http://doi.org/10.1002/(SICI)1098-2353(1999)12:1<43::AID-CA7>3.0.CO;2-W
Many apologies for the delay in the release of this podcast!
A second apology is due for the sound quality – it was recorded at a ‘live’ HEMS base – this has led to lots of background noise I am afraid. We have done our best to edit this out / reduce its effect but I’m afraid we are not experts in this area!
This podcast is part 2 of this series on the ventilator – and you should be familiar with the first in this series before progressing further!
Others have written excellent summaries of the themes of this podcast – please follow the links below:
This episode has been compiled over a year – many thanks to our four contributors, who have shared their stories and knowledge. They were interviewed at TraumaCare 2016, TraumaCare 2017 and the BASICS/FPHC Conference 2016.
If you ever need to talk about the impact of stresses and work experiences on you, please find a friend, colleague, GP, work Occupational Health Service, or one of the charities listed below.
Tony’s article describing his experience of providing medical care to those involved in the Shoreham air crash:
There is the potential for significant controversy in this month’s episode – and we would really appreciate the feedback of the prehospital community on this one.
We have held the ‘no clear fluids’ mantra close to our hearts for most of our prehospital careers. We ‘know’ that giving sea water to our patients, and diluting all of blood’s ‘good bits’ can’t be healthy. We believed in permissive hypotension – we were probably wrong.
Priorities for the bleeding trauma patient must include:
Minimum time to control of bleeding (tourniquets / haemostatics / knife / interventional radiology)
Appropriate choice of destination (knife / IR)
? Early correction of hypotension (especially if blunt trauma / associated head injury)
The balances of harms in the context of blunt trauma between the negative effects of infusing saline versus the negative effects of hypotension are unknown and prehospital actions need to be customised to an individual patient and situation.
In systems in which a potentially less harmful resuscitation strategy can be delivered sooner – PH systems with packed red cells / fresh frozen plasma / whole blood or freeze dried plasma, then it seems pragmatic to aim for normotension (predicted normal blood pressure) sooner in the patient’s care timeline than we have been e.g. at one hour. In patients with penetrating trauma permissive hypotension may remain useful for longer or at least until a patient can be differentiated and the bleeding controlled.
Penn-Barwell JG, Roberts SA, Midwinter MJ, Bishop JR: Improved survival in UK combat casualties from Iraq and Afghanistan: 2003-2012. J Trauma Acute Care Surg 78(5):1014–1020, 2015.
Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, et al.: Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care 19(1):1–9, 2015.
Weaver AE, Eshelby S, Norton J, Lockey DJ: The introduction of on-scene blood transfusion in a civilian physician-led pre-hospital trauma service. Scand J Trauma Resusc Emerg Med 21(Suppl1):S27, 2013.
Bodnar D, Rashford S, Williams S, Enraght-Moony E, Parker L, Clarke B: The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells. Emerg Med J 31(2):93–95, 2014.
Thanks to Mark Forrest (@ObiDoc) for sharing these videos:
Spurr J, Gatward J, Joshi N, Carley SD. Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments. EMJ. 2016.
Bredmose PP, Habig K, Davies G, Grier G, Lockey D. Scenario based outdoor simulation in pre-hospital trauma care using a simple mannequin model. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2010.
Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Quality & Safety. 2013; 22: 468-477.
Boet S, Bould MD, Layat Burn C, Reeves S. Twelve tips for a successful interprofessional team-based high-fidelity simulation educational session. Medical Teacher. 2014; 36: 853-857.
Smith JE, Rikard A, Wise D. Traumatic Cardiac Arrest. Journal of the Royal Society of Medicine 2015. 108(1): 11-16.
Wise et al. Emergency thoracotomy: “how to do it”. EMJ; 2005: 22-24.
Hunt et al. Emergency thoracotomy in thoracic trauma: a review. Injury; 2006 (37): 1-19.
Clay et al. Emergency Department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World Journal of Emergency Surgery; 2006: 1:4.
Rhee et al. Survival after Emergency Department thoracotomy: review of published data for last 25 years. J Am Coll Surg; 2000. 190(3): 288-298
ACS Committee on Trauma Working Group. Practice Management guidelines for ED Thoracotomy. J Am Coll Surg. 2001, 193 (3): 303-309.
Editorial. When should we stop resuscitative efforts after blunt traumatic arrest. Injury; 2008 (39): 967-969.
Joint Position Statement of Nat Assoc EMS Physicians and ACS Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital cardiopulmonary arrest. J Am Coll Surg; 2003 (1): 106-111.
Tarney et al.Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study. Resuscitation; 2011: 1194-1197
The location of an injury and involvement of different structures defines the stability of a spinal injury.
Anterior column: anterior longitudinal ligament and the anterior half of the vertebral body/disc.
Middle column: posterior half of the vertebral body/disc and the posterior longitudinal ligament.
Posterior column: facet joints, ligamentum flavum, the spinous processes and the interconnecting ligaments.
An injury involving only the anterior column is considered to be stable, as will an isolated fracture of a spinous or transverse process. An unstable injury is one which involves all 3 columns and often one in which 2 columns are disrupted.
Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510–8.
Oteir AO, Smith K, Stoelwinder JU, Middleton J, Jennings PA. Should suspected cervical spinal cord injury be immobilised?: A systematic review. Injury. Elsevier Ltd; 2015 Apr 1;46(4):528–35.
Smyth M, Cooke MW. Value of a rigid collar: in need of more research and better devices. Emergency Medicine Journal. 2013 May 13;30(6):516–6.
Crane T, Cooke MW, Wellings R, Wayte S, Higgins J. MRI study of effectiveness of cervical spine immobilisation- a pilot study. The University of Warwick. 2007 Aug 1;:1–18.
BOAST2: SPINAL CLEARANCE IN THE TRAUMA PATIENT. British Orthopaedic Association Standards for Trauma (BOAST); 2008. 1 p.
Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 2008 Apr 15;5(3):214–9.
Prasarn ML, Horodyski M, Dubose D, Small J, Del Rossi G, Zhou H, et al. Total Motion Generated in the Unstable Cervical Spine During Management of the Typical Trauma Patient. Spine. 2012 May;37(11):937–42.
Gill DS, Mitra B, Reeves F, Cameron PA, Fitzgerald M, Liew S, et al. Can initial clinical assessment exclude thoracolumbar vertebral injury? Emergency Medicine Journal. 2013 Jul 19;30(8):679–82.
Leech C, Porter K, Bosanko C. Log-rolling a blunt major trauma patient is inappropriate in the primary survey. Emergency Medicine Journal. 2013 Dec 22;31(1):86–6.
Horodyski M, Conrad BP, Del Rossi G, DiPaola CP, Rechtine GR II. Removing a Patient From the Spine Board: Is the Lift and Slide Safer Than the Log Roll? J Trauma. 2011 May;70(5):1282–5.
I J, A M, Yu E, Tulman D, Jones C, Stawicki S. A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients afternormal cervical spine CT. Journal of Emergencies, Trauma, and Shock. 2014 Feb 11;7(4):251–5.
Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. J Neurotrauma. 2014 Mar 15;31(6):531–40.
Armstrong BP, Simpson HK, Crouch R, Deakin CD. Prehospital clearance of the cervical spine: does it need to be a pain in the neck? Emerg Med J. 2007 Jul 1;24(7):501–3.
Connor D, Greaves I, Porter K, Bloch M, consensus group Faculty of Pre-Hospital Care. Pre-hospital spinal immobilisation: an initial consensus statement. Emerg Med J. 2013 Dec 1;30(12):1067–9.
Fattah S, Johnsen AS, Andersen JE, Vigerust T, Olsen T, Rehn M. Rapid extrication of entrapped victims in motor vehicle wreckage using a Norwegian chainmethod – cross-sectional and feasibility study. 2014 Jul 3;14(1):1–5.
Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ. 2008 Apr 22;178(9):1141–52.
Edwards MA, Verwey J, Herbert S, Horne S, Smith JE. Cervical spine clearance in the elderly: do elderly patients get a bad deal? Emerg Med J. 2013 May 23.
Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. J Neurotrauma. 2014 Mar 15;31(6):531–40.
Shafer JS, Naunheim RS. Cervical spine motion during extrication: a pilot study. West J Emerg Med. 2009 May;10(2):74–8.
Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma. 1993 Mar;34(3):342–6.
Hale DF, Fitzpatrick CM, Doski JJ, Stewart RM, Mueller DL. Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. Journal of Trauma and Acute Care Surgery. 2015 May;78(5):943–8.
Benger J, Blackham J. Why do we put cervical collars on conscious trauma patients? Scand J Trauma Resusc Emerg Med. 2009;17(1):44.
We have talked about ramping previously, in Episode 6: Oxygenation. This is how a pregnant patient should be positioned for airway manoeuvres and interventions, for example induction of anaesthesia and intubation.
The ILCOR 2015 update pertaining to Cardiac Arrest Associated with Pregnancy is accessible here:
Clark SL, Cotton DB, Pivarnik JM et al. Position change and central hemodynamic profile during normal third trimester pregnancy and post partum. Am J Obstetrics & Gynaecology. 1991; 164: 883-887.
Bamber JH, Dresner M. Aortocaval compression in pregnancy: the effect of changing the degree and direction of lateral tilt on maternal cardiac output. Anaesthesia & Analgesia. 2003; 97: 256-258.
Lee SWY, Khaw KS, Kee WN, Leung TY, Critchley LAH. Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women. British Journal of Anaesthesia. 2012; 109: 950-956.
We hope you enjoyed our sepsis podcast. It is obviously a huge topic and there is lots of information to cover; a couple of other recently released podcasts are available which are produced with the Emergency Medicine community in mind, but will no doubt expand your knowledge.
It was a single centre study which compared standard care with protocolised resuscitation packaged together as early goal-directed therapy (EGDT). This is what the study did:
As you will see the trial was relatively small – with only 263 patients being recruited into the trial. What was impressive, and changed practice, forming the basis of the Surviving Sepsis Campaign, was the significant reduction in mortality. Patients in the standard care group had a mortality of 46% compared with the treatment group 30%, which was statistically significant (p=0.009).
Further large randomized controlled studies to try and demonstrate the same mortality benefit from Rivers-style EGDT have not shown the same results (Process, Arise, PROMISe). Patients in these trials were randomly assigned to one of two groups. The ‘intervention’ group received the new treatment, in this case EGDT, which was being tested. The ‘standard care’ group were looked after according to how the clinician would usually treat a patient with severe sepsis. This was the same principle as in the Rivers trial: the standard care group is the ‘control’ group against which changes in outcome for the ‘intervention’ group are compared. The mortality in both groups in all 3 trials was similar, there was not the significant reduction in mortality seen in the Rivers study. This was probably because, as we say in the podcast, ‘standard’ care for sepsis has improved considerably in the intervening years. The control group received many similar treatments as the ‘intervention’ group (just not full protocolised EGDT) highlighting that with good sepsis care (fluid resuscitation, close monitoring, early appropriate antibiotic administration), mortality can be reduced.
Red flag sepsis is a way of identifying those patients with sepsis who are high risk and who warrant immediate treatment:
Have a look at the UK Sepsis Trust website: http://sepsistrust.org. There are toolkits available to download, including one specifically written for the prehospital environment with the College of Paramedics, which summarises the recognition and management of sepsis.
Reviewed (again for the Emergency Medicine community) here.
When Tim talks about test characteristics he is referring to the ability of a test to correctly identify the presence or absence of an illness. Some may think that if a test is positive it always means the patient has the illness, or indeed if it is negative it rules out the possibility of that illness but this is not the case with many of the tests we use.
Think about ECG as an example, So, where the box is green, the test has given us the correct result for the patient. But, where the box is red the test has given us the incorrect result: you will all be able to think about patients in whom the ECG was normal, but the patient turned out to have had an MI, or when the ECG showed an MI but the patient turned out not to have had one. These tables are used when assessing the usefulness of a test (or it’s sensitivity and specificity), and, when researching how useful tests are we need the majority of patients to fall into the green boxes.
We will put together a podcast on test characteristics over the next couple of months, which will explain this in more detail. An amazing podcast on the subject can be found at SMART EM: SMART Testing: Back to Basics
As always, any feedback, comments etc. – please let us know on the blog below!
Herlitz J, ng AB, m BW-S, Axelsson C, Bremer A, Hagiwara M, et al. Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care. Scand J Trauma Resusc Emerg Med. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine; 2012 Jun 27;20(1):1–1.
Studnek JR, Artho MR, Garner CL, Jones AE. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med. 2012 Jan;30(1):51–6.
Puskarich MA, Marchick MR, Kline JA, Steuerwald MT, Jones AE. One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. Crit Care. 2009;13(5):R167.
Seymour CW, Rea TD, Kahn JM, Walkey AJ, Yealy DM, Angus DC. Severe Sepsis in Pre-Hospital Emergency Care. Am J Respir Crit Care Med. 2012 Dec 15;186(12):1264–71.
Band RA, Gaieski DF, Hylton JH, Shofer FS, Goyal M, Meisel ZF. Arriving by Emergency Medical Services Improves Time to Treatment Endpoints for Patients With Severe Sepsis or Septic Shock. Academic Emergency Medicine. 2011 Aug 30;18(9):934–40.
Seymour CW, Cooke CR, Heckbert SR, Spertus JA, Callaway CW, Martin-Gill C, et al. Prehospital intravenous access and fluid resuscitation in severe sepsis: an observational cohort study. 2014 Oct 28;:1–9.
Trust US. You Gov Poll – Public Awareness of Sepsis. UK Sepsis Trust; 2014 Nov pp. 1–1.
MD GEH, MD RET, MD RS, MD JDL, BS AMB, BS AJS, et al. ACCEPTED MANUSCRIPT. Am J Emerg Med. Elsevier B.V; 2015 Aug 26;:1–31.
Amado Alejandro Baez MD MSc MFFF, MD LC. ACCEPTED MANUSCRIPT. Am J Emerg Med. Elsevier B.V; 2015 Oct 17;:1–16.
Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med. 2013 Jun;44(6):1116–25.
Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department*. Crit Care Med. 2010 Apr;38(4):1045–53.
Yealy DM, Huang DT, Delaney A, Knight M, Randolph AG, Daniels R, et al. Recognizing and managing sepsis: what needs to be done? ??? ??? 2015 Apr 24;:1–10.
Báez AA, Hanudel P, Perez MT, Giráldez EM, Wilcox SR. Prehospital Sepsis Project (PSP): knowledge and attitudes of United States advanced out-of-hospital care providers. Prehosp Disaster Med. 2013 Apr;28(2):104–6.
Harnden A. Parenteral penicillin for children with meningococcal disease before hospital admission: case-control study. BMJ. 2006 Jun 3;332(7553):1295–8.
Femling J, Weiss S, Hauswald E. EMS Patients and Walk-In Patients Presenting With Severe Sepsis: Differences in Management and Outcome. South Med J. 2014.
Gray A, Ward K, Lees F, Dewar C, Dickie S, McGuffie C, et al. The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments. Emergency Medicine Journal. 2013 Apr 12;30(5):397–401.
Seymour CW, Cooke CR, Mikkelsen ME, Hylton J, Rea TD, Goss CH, et al. Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care. 2010 Apr;14(2):145–52.
Hahné SJM, Charlett A, Purcell B, Samuelsson S, Camaroni I, Ehrhard I, et al. Effectiveness of antibiotics given before admission in reducing mortality from meningococcal disease: systematic review. BMJ. 2006 Jun 3;332(7553):1299–303.
Wang HE, Weaver MD, Shapiro NI, Yealy DM. Opportunities for Emergency Medical Services care of sepsis. Resuscitation. 2010 Feb;81(2):193–7
To provide a bit of balance following our earlier hyperoxia podcast, this episode we are discussing circumstances when we want to deliver extra oxygen to patients and ways to do this effectively, including an interview with Sydney HEMS Consultant Yash Wilmalasena on apnoeic oxygenation. Hope you find it useful!
Some of the stuff we talked about:
Optimal patient positioning when managing the airway and assisting ventilation has traditionally been taught as ‘sniffing the morning air’, shown here.
But now, learning from bariatric practice we are realising that ramping is better for airway optimisation. In this position the patient’s tragus is lined up with their sternal notch to make the airway as straight as possible.
This is a great (and entertaining!) video cast from Emergency Medicine colleagues in the States discussing and demonstrating techniques for optimal bag-valve-mask ventilation.
Wilmalasena Y, Burns B, Reid C, Ware S., Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Annals of Emergency Medicine. 2015; 65(4): 371-376.
Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. 2012; 59(3): 165-175.
Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Annals of Emergency Medicine. 2014; 65(4): 349-355.
Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the Emergency Department. The Journal of Emergency Medicine. 2010;
Grant S, Khan F, Keijzers G, Shirran M, Marneros L. Ventilator-assisted preoxygenation: protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator. Emergency Medicine Australasia. 2016: 28(1); 67-72.
Von Goedecke A, Wenzel V, Hormann C, Voelckel WG, Wagner-Berger HG, Zecha-Stallinger A, Luger TJ, Keller C. Effects of face mask ventilation in apneic patients with a resuscitation ventilator in comparision with a bag-valve-mask. Journal of Emergency Medicine. 2006: 30(1); 63-67.
Semier MW, Janz DR, Lentz RJ, Matthews DT, Norman BC, Assad TR, Keriwala RD, Ferrell BA, Noto MJ, McKown AC, Kocurek EG, Warren MA, Huerta LE, Rice TW. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. American Journal of Respiratory Critical Care Medicine. 2016; 193(3): 273-280. (FELLOW Trial)
Chilcott RP. Managing mass casualties and decontamination. Environmental International. 2014; 72: 37-45.
This is the Step 1,2,3 tool described:
For more information on the toxidromes associated with various chemicals, biological agents and radiation sources have a look at this document (admittedly it’s a few years old but the content is still good, especially the flow chart which is pasted below):
Anti-muscarinic = blocking the muscarinic receptors, ie blocking the effect of acetylcholine, hence also called anti-cholinergic. Impacts on parasympathetic stimulation. Antimuscarinic effects include dilated pupils (leading to blurred vision), reduced secretion of saliva (hence dry mouth), sweat and digestive juices. Relaxation of smooth muscle causing urinary retention, ileus. Also tachycardia, confusion progressing to delirum/coma.
Nerve agents inhibit anticholinesterase therefore there is an excess of acetylcholine resulting in opposite features: diarrhoea, urination, miosis, increased bronchial secretions, bronchoconstriction, vomiting, lacrimation, salivation.
Always ahead of the curve… St Emlyns have recently published a blog post on this very topic! It’s great, so have a read:
Hello and welcome to our next episode – we hope you enjoy it. This episode concentrates on hyperoxia – the delivery of lots (often too much) oxygen and the harms it may cause our patients. We both had colds – many apologies for the blocked noses and many sniffs!
We hope you find it useful.
To follow: Dr Matt Thomas from the Great Western Air Ambulance discussing his groups work around reducing hyperoxia post-rosc.
Cornet AD, Kooter AJ, Peters MJL, Smulders YM. The potential harm of oxygen therapy in medical emergencies. Crit Care. 2013 Apr 11;17(2):313.
Rincon F, Kang J, Maltenfort M, Vibbert M, Urtecho J, Athar MK, et al. Association Between Hyperoxia and Mortality After Stroke. Crit Care Med. 2014 Feb;42(2):387–96.
Stub D, Smith K, Bernard S, Bray J, Stephenson M, Cameron P, et al. A randomized controlled trial of oxygen therapy inacute myocardial infarction Air Verses Oxygen InmyocarDial infarction study (AVOID Study). American Heart Journal. Mosby, Inc; 2012 Mar 1;163(3):339–345.e1. 3. Asfar P, Singer M, Radermacher P. Understanding the benefits and harms of oxygen therapy. Intensive Care Med. 2015 Jan 30.
Calzia E, Asfar P, Hauser B, Matejovic M, Ballestra C, Radermacher P, et al. Hyperoxia may be beneficial. Crit Care Med. 2010 Oct;38:S559–68.
Asfar P, Calzia E, Huber-Lang M, Ignatius A, Radermacher P. Hyperoxia during septic shock–Dr. Jekyll or Mr. Hyde? Shock. 2011 Nov 21;37(1):122–3.
Cornet AD, Kooter AJ, Peters MJL, Smulders YM. The potential harm of oxygen therapy in medical emergencies. Crit Care. 2013 Apr 11;17(2):313.
Ligtenberg JJM, Stolmeijer R, Broekema JJ, Maaten ter JC, Zijlstra JG. A little less saturation? Crit Care. 2013 Jun 12;17(3):439.
Sorry for the slight delay releasing our “October” podcast – but here it is (note how it is cunningly labelled Episode 2)! This month we are reviewing the evidence for the pelvic binder and discussing scenarios in which it should (and should not) be used.
As always, please get in touch with questions and comments, either via the blog, twitter or email email@example.com
This is where the greater trochanters are:
This is where a binder should sit on the pelvis – it commonly ends up higher, either in application or ‘rides up’ during transfer – keep an eye on it!
These are the different types of fracture pattern that can occur in a pelvic fracture: of course patients can suffer from multiple force vectors so may end up with any combination of these fracture types.
Please click on this link below for our video on using a scoop to insert the pelvic binder…
As always… Get in touch!
Scott I, Porter K, Laird C, Greaves I, Bloch M. The prehospital management of pelvic fractures: initial consensus statement. EMJ. 2013; 30(12): 1070-1072.
Lee C, Porter K. The prehospital management of pelvic fractures. EMJ. 2007; 24: 130-133.
Prasarn ML, Conrad B, Small J, Horodyski M, Rechtine GR. Comparison of circumferential pelvic sheeting versus the T-POD on unstable pelvic injuries: A cadaveric study of stability. Injury. 2013; 44: 1756-1759.
Trebilcock H. Reducing overtriage and undertriage rates if pelvic fractures and unnecessary pelvic binder applications in major trauma patients. EMJ. 2015; 32(6): e17.
DeAngelis NA, Wixted JJ, Drew J, Eskander MS, Eskander JP, French BG. Use of the trauma pelvic orthotic device (T-POD) for provisional stabilisation of anterior-posterior compression type pelvic fractures: A cadaveric study. Injury. 2008; 39: 903-906.
Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. The Journal of Bone & Joint Surgery. 2002; 84A (2): 43-47.
Tan ECTH, van Stigt SFL, van Vugt AB. Effect of a new pelvic stabilizer (T-POD) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures. Injury. 2010; 41(12): 1239-1243.
Knops SP, Van Lieshout EMM, Spanjersberg WR, Patka P, Schipper IB. Randomised clinical trial comparing pressure characteristics of pelvic circumferential compression devices in healthy volunteers. Injury. 2011; 42(10): 1020-1026.
Mason LW, Boyce DE, Pallister I. Catastrophic myonecrosis following circumferential pelvic binding after massive crush injury: A case report. Injury Extra. 2009: 84-86.
Stewart M. BestBet: Pelvic circumferential compression devices for haemorrhage control: panacea or myth. EMJ. 2013; 30: 425-426.
Croce MA, Magnotti LJ, Savage SA, Wood GW, Fabian TC. Emergent pelvic fixation in patients with exsanguinating pelvic fractures. Journal of American College of Surgeons. 2007; 204: 935-942.
Knops SP, Schep NWL, Spoor CW, van Riel MPJM, Spanjersberg WR, Kleinrensink GJ, van Lieshout EMM, Patka P, Schipper IB. Comparison of three different pelvic circumferential compression devices: A biomechanical cadaver study. Journal of Bone & Joint Surgery. 2011; 93: 230-240.
Knops SP, van Riel MPJM, Goossens RHM, Lieshout EMM, Patka P, Schipper IB. Measurements of the exerted pressure by pelvic circumferential compression devices. The Open Orthopaedics Journal. 2010; 4: 101-106.
Here it is – our very first podcast, and guess what – it is on supraglottic airways!
This first episode reviews the history of the laryngeal mask airway and we discuss the relative benefits and risks of supraglottic airway devices. We’ve interviewed Dr Rob Moss, author of the Faculty of Prehospital Care (FPHC) Consensus Guidelines on pharmacologically assisted laryngeal mask (PALM) insertion. Click here for the link to the guideline.
We also met Professor Jonathan Benger and discuss the role of supraglottic devices in patients in cardiac arrest. Please have a look at the airways 2 trial website here.
References and resources:
Benger JR, Voss S, Coates D, Greenwood R, Nolan J, Rawstorne S, et al. Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of prehospital cardiac arrest (REVIVE-Airways): a feasibility study research protocol. BMJ Open. 2013 Jan 31;3(2):e002467–7.
Berlac P, Hyldmo PK, Kongstad P, Kurola J, Nakstad AR, Sandberg M. Pre-hospital airway management: guidelines from a task force from the Scandinavian Society for Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand. 2008 Jul 9;52(7):897–907.
Bosch J, de Nooij J, de Visser M, Cannegieter SC, Terpstra NJ, Heringhaus C, et al. Prehospital use in emergency patients of a laryngeal mask airway by ambulance paramedics is a safe and effective alternative for endotracheal intubation. Emergency Medicine Journal. 2014 Aug 14;31(9):750–3.
Cook T, Howes B. Supraglottic airway devices: recent advances. Continuing Education in Anaesthesia, Critical Care & Pain. 2011 Mar 15;11(2):56–61.
Deakin CD, Clarke T, Nolan J, Zideman DA, Gwinnutt C, Moore F, et al. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008. Emergency Medicine Journal. 2010 Mar 19;27(3):226–33.
Deakin CD, Peters R, Tomlinson P, Cassidy M. Securing the prehospital airway: a comparison of laryngeal mask insertion and endotracheal intubation by UK paramedics. Emergency Medicine Journal. 2004 Dec 20;22(1):64–7.
Gruber C, Nabecker S, Wohlfarth P, Ruetzler A, Roth D, Kimberger O, et al. Evaluation of airway management associated hands-off time during cardiopulmonary resuscitation: a randomised manikin follow-up study. Scand J Trauma Resusc Emerg Med. 2013;21:10.
Hasegawa K, Hiraide A, Chang Y, Brown DFM. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA. 2013 Jan 16;309(3):257–66.
Kajino K, Iwami T, Kitamura T, Daya M, Ong ME. Comparison of supraglottic airway versus endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest. Crit Care. 2011.
Mason AM. Prehospital Use of the Intubating Laryngeal Mask Airway in Patients with Severe Polytrauma: A Case Series. Case Reports in Medicine. 2009;2009(3):1–7.
Middleton PM, Simpson PM, Thomas RE, Bendall JC. Higher insertion success with the i-gel® supraglottic airway in out-of-hospital cardiac arrest: A randomised controlled trial. Resuscitation. 2014 Jul;85(7):893–7.
Moss R, Porter K, Greaves I, consensus group Faculty of Pre-Hospital Care. Pharmacologically assisted laryngeal mask insertion: a consensus statement. Emergency Medicine Journal. 2013 Dec;30(12):1073–5.
Ostermayer DG, Gausche-Hill M. Supraglottic Airways: The History and Current State of Prehospital Airway Adjuncts. Prehosp Emerg Care. 2014 Jan;18(1):106–15.